RESUMEN
STUDY DESIGN: This study retrospectively reviewed the intermediate-term clinical outcome of patients who were 50 years of age or older at the time they experienced their cervical spinal cord injury. OBJECTIVES: To establish reasonable expectations for the functional outcome in the older patient with cervical spinal cord injury. BACKGROUND DATA: The long-term morbidity and mortality of large groups of patients with spinal cord injury have been reported. The specific functional ability, disposition, morbidity, and mortality of this group of older patients injured after 50 years of age, however, have been less well defined. METHODS: Forty-one consecutive patients older than 50 years of age at the time of cervical cord injury were studied, and functional abilities, independence, need for assistance in activities of daily living, disposition, morbidity, and mortality were assessed. All patients had more than 2 years of follow-up examinations (mean, 5.5 years) by the same spine injury service. RESULTS: There were 13 complete and 28 incomplete cervical cord lesions. The mean age of the patients at follow-up examination was 67.5 years. The average follow-up period was 5.5 years after injury. None of the patients with complete cord injury improved, and all required extensive care. Twenty-one (80%) of 26 of the patients with incomplete cord injury were able to ambulate with some assistance. Nineteen of 26 patients had independent or near-independent abilities with activities of daily living. Twenty (77%) of 26 were able to return home. All patients with complete cord injury (13 of 13) had died by the time of the follow-up visit. Seventy-seven percent (10 of 13) of this patient group had died within the first year. Those surviving lived an average of 3.5 years after their injury. Fourteen of 28 patients with incomplete cord injury (50%) had died by the time of the follow-up visit. Six (43%) of the 14 deaths were attributed to complications of their spinal cord injury. CONCLUSION: The functional outcome of the person older than 50 years with a complete cervical cord injury is poor. Of the 14% who survived the first year, all required extensive attendant care, and no neurologic improvement was seen. The patient with an incomplete cord injury has an overall good outcome regarding ambulation and returning to home.
Asunto(s)
Envejecimiento/fisiología , Traumatismos de la Médula Espinal/epidemiología , Actividades Cotidianas , Anciano , Evaluación de la Discapacidad , Estudios de Seguimiento , Humanos , Esperanza de Vida , Morbilidad , Pronóstico , Traumatismos de la Médula Espinal/fisiopatología , Tasa de Supervivencia , Factores de TiempoRESUMEN
Fifty-five patients who had sustained a burst fracture of the lumbar spine were followed for a mean of seventy-nine months (range, twenty-four to 192 months) after the injury. Thirty patients had been managed non-operatively with a short period of bed rest followed by protected mobilization. The remaining twenty-five patients had been managed operatively: eight, with posterior arthrodesis with long-segment hook-and-rod fixation; eight, with posterior arthrodesis with short-segment transpedicular fixation; six, with posterior arthrodesis and instrumentation followed by anterior decompression and arthrodesis; and three, with anterior decompression and arthrodesis. Thirty-six patients had been neurologically intact at the time of presentation and had remained so throughout the follow-up period. No neurological deterioration or symptoms of late spinal stenosis were seen. Isolated partial single-nerve-root deficits resolved regardless of the method of treatment. Patients who had had a complete single or a multiple-nerve-root paralysis seemed to have benefited from anterior decompression. Although the anatomical results as seen on the most recent radiographs were superior for the group that had been managed operatively with long posterior fixation or anterior and posterior arthrodesis, the most recent pain scores and the functional outcomes were similar for all treatment groups. At the latest follow-up evaluation, some loss of spinal alignment was noted in the patients who had been managed with short transpedicular fixation; the alignment at the most recent follow-up examination was comparable with that in the patients who had been managed non-operatively. For the patients who had had non-operative treatment, we were unable to predict the deformity at the time of follow-up on the basis of the initial diagnostic radiographs. The clinical outcome was not related to the deformity at the latest follow-up evaluation. On the basis of the results of our study, we recommend non-operative treatment for patients who do not have neurological dysfunction or who have an isolated partial nerve-root deficit at the time of presentation. For patients who have a multiple-nerve-root paralysis, anterior decompression is indicated.
Asunto(s)
Vértebras Lumbares/lesiones , Fracturas de la Columna Vertebral/terapia , Actividades Cotidianas , Adolescente , Adulto , Anciano , Moldes Quirúrgicos , Femenino , Estudios de Seguimiento , Humanos , Fijadores Internos , Masculino , Persona de Mediana Edad , Dolor/diagnóstico , Parálisis/etiología , Estudios Retrospectivos , Fracturas de la Columna Vertebral/diagnóstico por imagen , Fracturas de la Columna Vertebral/cirugía , Fusión Vertebral , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
We conducted a survey to identify topics and skills in orthopaedics that should be included in a curriculum for the education of general practitioners. Forty-one program chairpersons responded to a questionnaire that asked respondents to rate the importance of each of eighty topics or skills related to orthopaedic surgery. The questionnaires were analyzed with use of descriptive statistics. The stability of the results was assessed with a follow-up questionnaire five months after the first survey had been completed, and the results were analyzed with a correlation coefficient of the mean ratings of importance and percentage agreement on individual items. The results produced a rank-order listing of important topics and skills in orthopaedics for the general practitioner. The topics and skills that were rated highly by program chairpersons corresponded to the types of musculoskeletal problems most commonly seen by family practitioners. This survey provides concurrent validity for the rank-order lists and confirms the need to include these items in a core curriculum for general practitioners.
Asunto(s)
Medicina Familiar y Comunitaria/educación , Ortopedia/educación , Competencia Clínica , Curriculum , Humanos , Reproducibilidad de los Resultados , Encuestas y CuestionariosRESUMEN
STUDY DESIGN: Case report. OBJECTIVE: To acknowledge a potential serious complication of Gelfoam use in enclosed space. SUMMARY OF BACKGROUND DATA: The gelatin sponge has been used for hemostasis in spine surgery. Its complication rate is very low, but it has the potential for compression of vital tissues when left next to the spinal cord within an enclosed space. METHOD: Case report. RESULTS: Retained Gelfoam sponges were found in an enclosed space next to the spinal cord. These expanded and compromised the spinal cord. CONCLUSION: There is potential for expansion of the Gelfoam sponge in enclosed spaces after spinal surgery. There is the possibility of neurologic compromise in these cases. Gelfoam should be removed.
Asunto(s)
Esponja de Gelatina Absorbible/efectos adversos , Cuadriplejía/etiología , Médula Espinal/cirugía , Anciano , Femenino , Humanos , Imagen por Resonancia Magnética , Compresión de la Médula Espinal/etiología , Fusión Vertebral/instrumentación , Fusión Vertebral/métodosRESUMEN
STUDY DESIGN: This study retrospectively reviewed consecutive spinal cord injured patients older than 50 years of age. OBJECTIVE: This study established reasonable expectations for the early clinical outcome of cervical spinal cord injured patients greater than 50 years of age. SUMMARY OF BACKGROUND DATA: Previous studies of cervical spinal cord injuries have concentrated on long-term morbidity and mortality. Little data has been reported on the early clinical outcome during rehabilitation. METHODS: Forty-two consecutive patients older than 50 years of age at the time of cervical cord injury were reviewed. Data was collected from the time of injury to discharge from rehabilitation (< 4 months) and included morbidity, mortality, and disposition of the patient. RESULTS: There were 15 complete and 27 incomplete cervical cord lesions. Forty-five percent were caused by falls, 42% by motor vehicle accidents. Serious associated morbidity was 81% in complete cord injuries and 34% in incomplete lesions. Overall mortality was 23%. Complete cord injury mortality rate was 60% in this age group. All patients over 65 years of age with complete cord injuries died. CONCLUSIONS: Incomplete cervical cord lesions have the best prognosis for return to home and a functional lifestyle. Complete cervical cord injuries in patients older than 50 years of age have a 60% mortality rate. Complete cervical cord injuries in patients over 65 years have a poor prognosis for survival.
Asunto(s)
Traumatismos de la Médula Espinal/rehabilitación , Anciano , Anciano de 80 o más Años , Humanos , Persona de Mediana Edad , Morbilidad , Cuello , Estudios Retrospectivos , Traumatismos de la Médula Espinal/epidemiología , Traumatismos de la Médula Espinal/mortalidad , Análisis de Supervivencia , Factores de Tiempo , Resultado del TratamientoRESUMEN
Ninety-nine patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) were prospectively studied for deep venous thrombosis (DVT) of the lower extremity. Eighty-three hips in 42 THA patients and 107 knees in 57 TKA patients were studied with noninvasive color duplex Doppler ultrasound flow scanning and ascending venography 3-9 days after surgery. In all patients, surveillance studies were performed within 24 hours. The ultrasonographer and radiologist were blinded to the study. The incidence of DVT was significantly greater following TKA (61%) than THA (17%) (P < .001). After TKA, significantly more DVT was found in the ipsilateral (32 of 57 patients) versus contralateral knees (3 of 50 patients), and more thrombi were located below the knee (34 of 107 knees) than above the knee (1 of 107 knees) (P < .001). More thrombi were found in the contralateral limb after THA (5 of 41 patients vs 3 of 42 patients), but this was not significant. Two patients developed nonfatal pulmonary emboli. The sensitivity of color flow scanning was relatively poor initially (67% of above-knee patients and 57% of below-knee patients), but improved in the last 50 patients (100% of above-knee patients and 79% of below-knee patients). Negative predictive values exceeded 90% in the THA group and 87% in the TKA group. Positive predictive values ranged from 89 to 100%. Specificity was always above 96%. Longitudinal ultrasound scanning with the newer Quantum 2000 angiodynograph (Issaquah, WA) provided the best image quality.(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Prótesis de Cadera/efectos adversos , Prótesis de la Rodilla/efectos adversos , Tromboflebitis/diagnóstico por imagen , Ultrasonografía Doppler en Color , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos , Sensibilidad y Especificidad , Tromboflebitis/etiologíaRESUMEN
A debilitated 73-year-old white man was diagnosed with back pain secondary to acute hematogenous Eikenella corrodens vertebral osteomyelitis on the basis of history and physical examination, radiographs, computed tomography, magnetic resonance imaging, and open biopsy of the L3 vertebral body. A rare cause of vertebral osteomyelitis, possibly reported only once before in the world literature, E. corrodens is a facultative anaerobic gram-negative bacillus and a normal oral inhabitant. E. corrodens should be considered in the differential diagnosis of vertebral osteomyelitis and can be managed with immobilization and long-term intravenous antibiotics.
Asunto(s)
Eikenella corrodens , Infecciones por Bacterias Gramnegativas/epidemiología , Vértebras Lumbares , Osteomielitis/microbiología , Anciano , Infecciones por Bacterias Gramnegativas/tratamiento farmacológico , Humanos , Masculino , Osteomielitis/tratamiento farmacológico , Penicilina G/uso terapéuticoRESUMEN
Ochronosis, the musculoskeletal manifestation of alkaptonuria, primarily involves the larger joints of the body, including the spine. Ankylosis of the thoracolumbar spine leads to progressive loss of flexibility. The case described is that of a 72-year-old man with ochronosis who suffered a hyperextension injury to his spine in a fall, resulting in a fracture through an ankylosed L2-L3 disk space. To the authors' knowledge, this is the first reported fracture of an ankylosed ochronotic spine.
Asunto(s)
Vértebras Lumbares/lesiones , Ocronosis/complicaciones , Fracturas de la Columna Vertebral/etiología , Anciano , Humanos , Vértebras Lumbares/diagnóstico por imagen , Masculino , Radiografía , Fracturas de la Columna Vertebral/diagnóstico por imagenRESUMEN
Anterior ankle dislocations without concomitant malleolar fractures are rare injuries. Review of the English-language literature disclosed only three previously reported cases. A 21-year-old man sustained an isolated anterior ankle dislocation with an associated fracture of the trigonal process, which was reduced without difficulty. At follow-up examination 33 months later, the patient's major complaint was chronic, posttraumatic peroneal tendon dislocation. The proposed mechanism of injury suggested in this case is forced plantar flexion.
Asunto(s)
Traumatismos del Tobillo/terapia , Fracturas Óseas/terapia , Luxaciones Articulares/terapia , Adulto , Traumatismos del Tobillo/diagnóstico por imagen , Fracturas Óseas/diagnóstico por imagen , Humanos , Luxaciones Articulares/diagnóstico por imagen , Masculino , RadiografíaRESUMEN
Burst fracture of the fifth lumbar vertebra is a rare injury. We report the cases of seven patients who were treated conservatively by immobilization for six to eight weeks in a body-jacket cast that included one lower extremity to the knee. The patients were allowed to walk ten to fourteen days after the injury. A thoracolumbosacral orthosis was worn for an additional three months. No patient had an injury to the sacral root. Two patients had mild lower lumbar motor-root deficits that resolved within one year. All patients had an occasional backache, and two had intermittent radicular-type pain in the distribution of the fifth lumbar or first sacral-nerve root. The degree of compromise of the spinal canal could not be directly related to the degree of neurological deficit; that is, a large compromise of the spinal canal did not necessarily result in a major loss of neurological function. There was no early or late loss of lordosis between the cephalad end-plate of the fourth lumbar vertebra and the cephalad aspect of the sacrum, and there were no signs of progressive collapse of the vertebral body in any patient. In our series, the burst fractures of the fifth lumbar vertebra were stable injuries that caused minimum neurological deficits, and treatment by immobilization in a body-jacket cast was effective.
Asunto(s)
Vértebras Lumbares/lesiones , Fracturas de la Columna Vertebral/terapia , Adulto , Moldes Quirúrgicos , Femenino , Estudios de Seguimiento , Fijación de Fractura/métodos , Humanos , Inmovilización , Lordosis/etiología , Masculino , Persona de Mediana Edad , Fracturas de la Columna Vertebral/complicaciones , Estenosis Espinal/etiología , Resultado del TratamientoRESUMEN
Compared with conventional duplex imaging, color-flow scanning facilitates the identification of veins (especially below the knee), decreases the need to assess Doppler flow patterns and venous compressibility, and allows veins to be surveyed longitudinally. These advantages translate into a less demanding and time-consuming examination. This study was designed to determine the accuracy of color-flow scanning for detecting acute deep venous thrombosis in patients in whom the diagnosis is clinically suspected and in asymptomatic patients at high risk for developing postoperative deep venous thrombosis. The diagnostic group included 77 limbs of 75 patients, and the surveillance group included 190 limbs of 99 patients undergoing total hip or knee replacement. All patients were prospectively examined with color-flow scanning and phlebography. In the diagnostic group, the incidence of thrombi in below-knee veins (47%) was approximately equal to that in above-knee veins (43%); but in the surveillance group, the incidence of thrombi in below-knee veins (41%) far exceeded that in veins above the-knee (3%). Nonocclusive clots and clots isolated to a single venous segment were more common in the surveillance group. In symptomatic patients, color-flow scanning was 100% sensitive and 98% specific above the knee and 94% sensitive and 75% specific below the knee. In the surveillance group, color-flow scanning was significantly (p less than 0.001) less sensitive (55%) for detecting thrombi, 93% of which were confined to the tibioperoneal veins. Negative predictive values were 100% and 88% for the diagnostic and surveillance limbs, respectively. Positive predictive values were 80% for the diagnostic limbs and 89% for the surveillance limbs. Color-flow scanning effectively excludes above-knee deep venous thrombosis in symptomatic patients and asymptomatic high-risk patients and predicts the presence of above-knee thrombi in patients in the diagnostic group with reasonable accuracy (97%). We conclude that color-flow scanning is as accurate as conventional duplex imaging and, because of its advantages, is the noninvasive method of choice for evaluating patients with suspected deep venous thrombosis. Its role in the surveillance of patients at high risk remains to be determined and awaits further clinical evaluation.
Asunto(s)
Tromboflebitis/diagnóstico por imagen , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Distribución de Chi-Cuadrado , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Flebografía , Valor Predictivo de las Pruebas , Estudios Prospectivos , Sensibilidad y Especificidad , Tromboflebitis/etiología , Factores de Tiempo , UltrasonografíaRESUMEN
The effect of fused segments in the cervical spine has been documented to cause chronic changes in adjacent levels. This article reports an association between the presence of fused cervical segments and the predisposition to acute, traumatic instability at adjacent levels. Patients with cervical fractures were reviewed during a 12-year period. Fifteen patients were identified who sustained cervical fractures in the presence of previously fused segments. The presence of fusion was reviewed for its effect of neurologic injury, delay in diagnosis, and patterns of fractures. The diagnostic studies used to document instability were reviewed. We found that preexisting cervical fusions often result in a delay of diagnosis because of altered anatomy and atypical fracture patterns. The fractures occurred within one or two levels from the fused segment. There are different fracture patterns associated with fusions in the upper cervical spine and those fusions in the lower cervical spine. The presence of fusions significantly affected treatment choices in this group of patients.
Asunto(s)
Vértebras Cervicales/lesiones , Complicaciones Posoperatorias/epidemiología , Fracturas de la Columna Vertebral/epidemiología , Fusión Vertebral , Adulto , Anciano , Anciano de 80 o más Años , Artritis/complicaciones , Vértebras Cervicales/anomalías , Vértebras Cervicales/patología , Vértebras Cervicales/cirugía , Susceptibilidad a Enfermedades/etiología , Femenino , Humanos , Síndrome de Klippel-Feil/complicaciones , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Estudios Prospectivos , Cuadriplejía/etiología , Traumatismos de la Médula Espinal/etiología , Fracturas de la Columna Vertebral/diagnóstico , Fracturas de la Columna Vertebral/etiología , Fusión Vertebral/efectos adversos , Osteofitosis Vertebral/complicaciones , Estrés MecánicoRESUMEN
The properties of the omentum and its effect on spinal neurologic disease was investigated. Omental pedicle grafts were transferred to the laminectomized lumbar spines of nine neurologically normal dogs. Grafts were placed on either the dura or the spinal cord. Interruption of the graft's circulation was examined. To study the effect, the artery of the graft was injected with contrast and the graft-dura interface studied histologically. All injected specimens demonstrated vascular connections from the graft to the neural elements. The graft was found to decrease postoperative perineural scarring. The omentum appears to possess properties that could be applied to improve outcomes in spinal surgery.
Asunto(s)
Laminectomía , Epiplón/trasplante , Médula Espinal/irrigación sanguínea , Nervios Espinales/cirugía , Colgajos Quirúrgicos , Animales , Aracnoiditis/prevención & control , Perros , Laminectomía/efectos adversos , Vértebras Lumbares/cirugía , Microcirculación/fisiología , Complicaciones Posoperatorias/prevención & control , Traumatismos de la Médula Espinal/etiología , Nervios Espinales/lesionesRESUMEN
Vertebral osteomyelitis due to hematogenous seeding of Streptococcus agalactiae occurred in a 29-year-old farmer. The patient was treated with immobilization and parenteral antibiotics but developed recurrent back pain requiring a posterior spinal fusion. In a review of the literature, Group B streptococcal vertebral osteomyelitis seems not to have been previously reported in an adult.
Asunto(s)
Osteomielitis/etiología , Espondilitis/etiología , Infecciones Estreptocócicas/complicaciones , Adulto , Dolor de Espalda/diagnóstico , Dolor de Espalda/etiología , Dolor de Espalda/cirugía , Terapia Combinada , Enfermedades del Pie/complicaciones , Enfermedades del Pie/diagnóstico , Enfermedades del Pie/microbiología , Enfermedades del Pie/terapia , Humanos , Masculino , Osteomielitis/complicaciones , Osteomielitis/diagnóstico , Osteomielitis/microbiología , Osteomielitis/terapia , Recurrencia , Sepsis/complicaciones , Sepsis/diagnóstico , Sepsis/microbiología , Sepsis/terapia , Fusión Vertebral , Espondilitis/complicaciones , Espondilitis/diagnóstico , Espondilitis/microbiología , Espondilitis/terapia , Infecciones Estreptocócicas/diagnóstico , Infecciones Estreptocócicas/microbiología , Infecciones Estreptocócicas/terapia , Streptococcus agalactiae/aislamiento & purificación , Dedos del PieRESUMEN
Two categories of persistent posttraumatic neurologic deficits of the spinal cord without evidence of a spinal fracture or dislocation have been described previously. Spinal cord injury without radiographic abnormality (SCI-WORA) is seen in children. In the elderly, hyperextension injuries causing neurologic deficits without bony injury have also been described. The purpose of this report is to review mechanisms by which transient neurologic deficits occur in the absence of bony disruption. The authors describe four cases in which transient neurologic deficits occurred after blunt trauma to the thoracic or lumbar spine. Their experience indicates that, when neurologic deficits after trauma occur without fracture or dislocation, there is often an underlying structural susceptibility of the axial skeleton.
Asunto(s)
Vértebras Lumbares/lesiones , Enfermedades del Sistema Nervioso/etiología , Traumatismos de la Médula Espinal/etiología , Vértebras Torácicas/lesiones , Heridas no Penetrantes/complicaciones , Adolescente , Adulto , Anciano , Humanos , Masculino , Factores de TiempoRESUMEN
Injuries to the subaxial cervical spine must be suspected in any patient who suffers a head injury or complains of neck pain or neurologic symptoms of the arms or legs following an accident, particularly a motor vehicle or diving accident. Careful neurologic examination and lateral roentgenograms are indicated in all patients with suspected injury. If there is any neurologic deficit, fracture, or dislocation seen on roentgenogram, skull-traction tongs should be applied to provide stability and prevent further damage. If the neurologic examination and roentgenograms are normal, a stretch-test roentgenogram may be indicated to detect an occult ligamentous injury. Muscular strains and first-degree sprains may be treated with a collar and early active exercise. Subluxation and facet dislocations are most reliably treated with a posterior one-level fusion. Comminuted body fractures are best treated with an anterior strut graft. Complex fracture-dislocations of both anterior and posterior columns may be best treated with skull traction followed by combined anterior and posterior stabilization. Halo-jacket immobilization has few indications in subaxial injuries. It does not provide enough stability to maintain reduction of unstable mid- and low-cervical injuries. It may be used for postoperative immobilization in very unstable situations, but its greatest use is in immobilization of C1 and C2 fractures.
Asunto(s)
Vértebra Cervical Axis/lesiones , Traumatismos Vertebrales/diagnóstico , Vértebra Cervical Axis/diagnóstico por imagen , Vértebra Cervical Axis/cirugía , Vértebras Cervicales/diagnóstico por imagen , Fracturas Óseas/diagnóstico por imagen , Fracturas Óseas/cirugía , Humanos , Luxaciones Articulares/diagnóstico por imagen , Ligamentos/lesiones , Traumatismos Vertebrales/diagnóstico por imagen , Traumatismos Vertebrales/cirugía , Esguinces y Distensiones/diagnóstico , Tomografía Computarizada por Rayos XRESUMEN
Neoplastic destructive disease involving the subtrochanteric region of the femur is a difficult condition to treat. This is a retrospective study of 11 femurs in 10 patients with subtrochanteric destructive lesions or pathologic fractures that were stabilized with the Zickel intramedullary device. The study investigated underlying disease process, ambulatory status, operative parameters, time to death, and associated metastasis. The average survival time of the patients who died was 4.7 months. All of the patients involved in this study could be mobilized, but only 3 out of 10 were ambulatory. This study concludes that the intramedullary fixation of pathologic fractures or lesions of the subtrochanteric region does not necessarily allow ambulation, but does allow mobilization of debilitated patients.
Asunto(s)
Fracturas del Cuello Femoral/cirugía , Neoplasias Femorales/complicaciones , Fijación Intramedular de Fracturas , Fracturas Espontáneas/cirugía , Anciano , Ambulación Precoz , Femenino , Fracturas del Cuello Femoral/etiología , Fracturas Espontáneas/etiología , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
Surgical stabilization of the cervical spine for maintaining reduction and facilitating fusion following trauma may be accomplished by wiring the dorsal elements together. Twenty gauge (0.8 mm) 316L stainless steel surgical wire is the most convenient size to use. Meticulous atraumatic technique is necessary to reduce and fix the unstable spine in order to prevent damage to the spinal cord. Multiple wiring techniques of the upper and lower cervical spine are described and demonstrated, noting the advantages and disadvantages of each.